The association of comorbid depression with mortality in patients with type 2 diabetes

OBJECTIVE

We assessed whether patients with comorbid minor and major depression and type 2 diabetes had a higher mortality rate over a 3-year period compared with patients with diabetes alone.

RESEARCH DESIGN AND METHODS

In a large health maintenance organization (HMO), 4,154 patients with type 2 diabetes were surveyed and followed for up to 3 years. Patients initially filled out a written questionnaire, and HMO-automated diagnostic, laboratory, and pharmacy data and Washington State mortality data were collected to assess diabetes complications and deaths. Cox proportional hazards regression models were used to calculate adjusted hazard ratios of death for each group compared with the reference group.

RESULTS

There were 275 (8.3%) deaths in 3,303 patients without depression compared with 48 (13.6%) deaths in 354 patients with minor depression and 59 (11.9%) deaths among 497 patients with major depression. A proportional hazards model with adjustment for age, sex, race/ethnicity, and educational attainment found that compared with the nondepressed group, minor depression was associated with a 1.67-fold increase in mortality (P = 0.003), and major depression was associated with a 2.30-fold increase (P < 0.0001). In a second model that controlled for multiple potential mediators, both minor and major depression remained significant predictors of mortality.

CONCLUSIONS

Among patients with diabetes, both minor and major depression are strongly associated with increased mortality. Further research will be necessary to disentangle causal relationships among depression, behavioral risk factors (adherence to medical regimens), diabetes complications, and mortality.

Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study

OBJECTIVE

The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) evaluated the impact of a care management intervention on suicidal ideation and depression in older primary care patients. This is the first report of outcomes over a 2-year period.

METHOD

Study participants were patients 60 years of age or older (N=599) with major or minor depression selected after screening 9,072 randomly identified patients of 20 primary care practices randomly assigned to provide either the PROSPECT intervention or usual care. The intervention consisted of services of 15 trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 24 months.

RESULTS

Compared with patients receiving usual care, those receiving the intervention had a higher likelihood of receiving antidepressants and/or psychotherapy (84.9%-89% versus 49%-62%) and had a 2.2 times greater decline in suicidal ideation over 24 months. Treatment response occurred earlier on average in the intervention group and increased from months 18 to 24, while no appreciable increase in treatment response occurred in the usual care group during the same period. Among patients with major depression, a greater number achieved remission in the intervention group than in the usual-care group at 4 months (26.6% versus 15.2%), 8 months (36% versus 22.5%), and 24 months (45.4% versus 31.5%). Patients with minor depression had favorable outcomes regardless of treatment assignment.

CONCLUSIONS

Sustained collaborative care maintains high utilization of depression treatment, reduces suicidal ideation, and improves the outcomes of major depression over 2 years.

Clinical predictors of suicide in primary major depressive disorder

OBJECTIVE

Follow-up studies of patients with depressive disorders have identified only a few replicable predictors of suicide and have not explored possible interactions between them. The following analysis takes advantage of a large cohort of depressed patients given detailed, structured interviews 2 decades ago.

METHOD

The data set on which this analysis is based was collected between 1976 and 1990. Research personnel administered the Schedule for Affective Disorders and Schizophrenia to 785 adults who had major depressive disorder (Research Diagnostic Criteria) but who lacked other Axis I disorders. The current analysis used the National Death Index to determine mortality status as of 2003.

RESULTS

One in 4 of the 134 deaths were by suicide for an overall suicide rate of 4.2%. In comparison to the remaining 752 patients, the 33 who died by suicide were more likely to have been inpatients and to have had a history of suicide attempts at the time of baseline assessment. They had also expressed more hopelessness and had higher ratings of suicidal tendency. The last of these variables was the most robust by far and, when tested with other predictors in regression analyses, was the only one to retain significance (p < .0001). No interactions between predictors emerged. As in an earlier, similar study, the suicidal tendency rating was predictive of suicides that occurred after the first year of follow-up, which suggests that suicidal tendencies comprise a trait that persists across episodes.

CONCLUSION

A global rating of suicidality appears to be the single most important predictor of eventual suicide in patients with major depressive disorder.

Is low dietary intake of omega-3 fatty acids associated with depression?

OBJECTIVE

This study examined the association between the dietary intake of omega-3 fatty acids and low mood, major depression, and suicide.

METHOD

A total of 29,133 men ages 50 to 69 years participated in a population-based trial in Finland. The intake of fatty acids and fish consumption were calculated from a diet history questionnaire. Self-reported depressed mood was recorded three times annually, data on hospital treatments due to a major depressive disorder were derived from the National Hospital Discharge Register, and suicides were identified from death certificates.

RESULTS

There were no associations between the dietary intake of omega-3 fatty acids or fish consumption and depressed mood, major depressive episodes, or suicide.

CONCLUSIONS

Dietary intake of omega-3 fatty acids showed no association with low mood level.

Association of anhedonia with recurrent major adverse cardiac events and mortality 1 year after acute coronary syndrome

CONTEXT

Depression consistently predicts recurrent events and mortality in patients with acute coronary syndrome (ACS), but it has 2 core diagnostic criteria with distinct biological correlates-depressed mood and anhedonia (loss of pleasure or interest).

OBJECTIVE

To determine if depressed mood and/or anhedonia predict 1-year medical outcomes for patients with ACS.

DESIGN

Observational cohort study of post-ACS patients hospitalized between May 2003 and June 2005. Within 1 week of admission, patients underwent a structured psychiatric interview assessing clinically impairing depressed mood, anhedonia, and major depressive episode (MDE). Also assessed were the Global Registry of Acute Coronary Events risk score, Charlson comorbidity index, left ventricular ejection fraction, antidepressant use, and depressive symptom severity using the Beck Depression Inventory.

SETTING

Cardiac units of 3 university hospitals in New York and Connecticut.

PARTICIPANTS

Consecutive sample of 453 patients with ACS (age, 25-93 years; 42% women).

MAIN OUTCOMES MEASURES

All-cause mortality (ACM) and documented major adverse cardiac events (MACEs)-myocardial infarction, hospitalization for unstable angina, or urgent/emergency coronary revascularization)-actively surveyed for 1 year after admission.

RESULTS

There were 67 events (16 deaths and 51 MACEs; 14.8%): 108 (24%) and 77 (17%) patients had anhedonia and depressed mood, respectively. Controlling for sex, age, and medical covariates, anhedonia (adjusted hazard ratio, 1.58; 95% confidence interval, 1.16-2.14; P < .01) was a significant predictor of combined MACE and ACM, but depressed mood was not. Anhedonia continued to significantly predict outcomes (P < .05) when additionally controlling for MDE diagnosis or depressive symptom severity. Findings were confirmed using depressed mood and anhedonia subscores from the Beck Depression Inventory in place of clinician interview ratings.

CONCLUSIONS

Anhedonia identifies risk of MACE and ACM beyond that of established medical prognostic indicators, including MDE and depressive symptom severity. Correlates of anhedonia may add to the understanding of the link between depression and heart disease.

Psychiatric comorbidity and suicide risk in adolescents with chronic daily headache

OBJECTIVES

To investigate the prevalence and correlates of comorbid psychiatric disorders and suicidal risk in community-based adolescents with chronic daily headache (CDH).

METHODS

We identified and recruited 122 adolescents with CDH from a non-referral student sample (n = 7,900). CDH subtypes were classified according to the most updated criteria of the International Classification of Headache Disorders, 2nd edition (ICHD-2). An in-person psychiatric interview was performed with each subject with CDH to assess depressive and anxiety disorders and suicidal risk based on the Mini-International Neuropsychiatric Interview-Kid (MINI-Kid). Clinical correlates and impacts were investigated.

RESULTS

A total of 121 subjects (31 male/90 female, mean age 13.8 years) finished the psychiatric interview. Fifty-seven subjects (47%) had > or =1 assessed psychiatric comorbidity with major depression (21%) and panic disorder (19%) as the two most common diagnoses. Current suicidal risk was assessed as high (score > or = 10) in 20% of subjects. Female gender and older age were associated with depressive disorders. Presence of migraine was associated with psychiatric comorbidities (OR = 3.5, p = 0.002). The associations with psychiatric disorders were stronger for migraine with aura than for migraine without aura. Migraine with aura also independently predicted a high suicidal risk (score > or = 10) (adjusted OR = 6.0, p = 0.028). In contrast, CDH subtypes, headache frequencies, or medication overuse were not correlated. Comorbid psychiatric disorders were not related to physician consultations or more days of sick leave.

CONCLUSIONS

This community-based study showed high comorbidity of psychiatric disorders and suicidal risk in adolescents with chronic daily headache. The presence of migraine attacks, especially migraine with aura, was the major predictor for these associations.

Depression and leukocyte telomere length in patients with coronary heart disease: data from the Heart and Soul Study

OBJECTIVE

Shortened telomere length has been associated with mortality in patients with coronary heart disease (CHD) and is considered as an emerging marker of biologic age. Whether depression is associated with telomere length or trajectory has not been evaluated in patients with CHD.

METHODS

In a prospective cohort study, we measured leukocyte telomere length in 952 participants with stable CHD at baseline and in 608 of these participants after 5 years of follow-up. The presence of major depressive disorder in the past month was assessed using the computerized diagnostic interview schedule at baseline. We used linear and logistic regression models to evaluate the association of depression with baseline and 5-year change in leukocyte telomere length.

RESULTS

Of the 952 participants, 206 (22%) had major depression at baseline. After the adjustment for age and sex, the patients with current major depressive disorder had shorter baseline telomere length than those without depression (mean [standard error] = 0.86 [0.02] versus 0.90 [0.01]; p = .02). This association was similar (but no longer statistically significant) after adjustment for body mass index, smoking, diabetes, left ventricular ejection fraction, statin use, antidepressant use, physical inactivity, and anxiety (0.85 [0.02] versus 0.89 [0.01], p = .06). Depression was not predictive of 5-year change in telomere length after adjustment for the mentioned covariates and baseline telomere length.

CONCLUSIONS

Depression is associated with reduced leukocyte telomere length in patients with CHD but does not predict 5-year change in telomere length. Future research is necessary to elucidate the potential mechanisms underlying the association between depression and telomere length.

Is depression in old age fatal only when people feel lonely?

OBJECTIVE

The impact of depression and perceived loneliness in the oldest old is largely unknown. The authors studied the relationship between the presence of depressive symptoms and all-cause mortality in old age, especially the potential distorting effect of perceived loneliness.

METHOD

Within a prospective population-based study of 85-year-olds, the 15-item Geriatric Depression Scale and the Loneliness Scale were annually applied in all 476 participants with a Mini-Mental State Examination score of 18 points or more.

RESULTS

Depression was present in 23% and associated with marital state, institutionalization, and perceived loneliness. When depression and perceived loneliness were assessed during follow-up, neither depression nor perceived loneliness had a significant effect on mortality. However, those who suffered from both depression and feelings of loneliness had a 2.1 times higher mortality risk.

CONCLUSIONS

The data suggest that the increased mortality risk attributable to depression in the presence of perceived loneliness may result from motivational depletion.

Preventing suicide and premature death by education and treatment

Suicide is a leading cause of mortality. It is, in principle, preventable - given the fact that we possess effective treatments for depressive illness, the major contributor to such mortality. Nonetheless, complex logistic problems have prevented the institution of successful suicide prevention programs. The present review summarizes the author's work on the island of Gotland in Sweden, where the small size of the population permitted the institution of an educational and treatment program aimed at the general medical practitioners. The program was successful in reducing suicide rates by 60%. This was accompanied by reduction of different indices measuring depressive morbidity. Prevention was successful for as long as the program was instituted. The author provides his reflections on the public health implications of his data - particularly for Eastern Europe which is experiencing widespread stress in the workplace and in economic situations. More hypothetically, he presents his views on a serotonin-mediated 'male suicide syndrome'.

Male depression and suicide

Based on the experiences of the Gotland Study that education of general practitioners about depressive illness resulted in a statistically significant reduction in the number of female suicides, leaving the rate of male suicides almost unaffected, we propose the concept of a male depressive syndrome. This syndrome comprises a low stress tolerance, an acting-out behavior, a low impulse control, substance abuse and a hereditary loading of depressive illness, alcoholism and suicide. This notion is supported by data from The Amish study as well as the concept of van Praag of a stress-precipitated, cortisol-induced, serotonin-related and anxiety-driven depressive illness most often seen in males. In order to identify depressed males, the Gotland Male Depression Scale has been developed. Some preliminary data using the scale in a group of alcohol-dependant patients are presented.

Seasonal spring peaks of suicide in victims with and without prior history of hospitalization for mood disorders

BACKGROUND

Seasonal spring peaks of suicide are highly replicated, but their origin is poorly understood. As the peak of suicide in spring could be a consequence of decompensation of mood disorders in spring, we hypothesized that prior history of mood disorders is predictively associated with suicide in spring.

METHODS

We analyzed the monthly rates of suicide based upon all 37,987 suicide cases in the Danish Cause of Death Registry from 1970 to 2001. History of mood disorder was obtained from the Danish Psychiatric Central Register and socioeconomical data from the Integrated Database for Labour Market Research. The monthly rate ratio of suicide relative to December was estimated using a Poisson regression. Seasonality of suicide between individuals with versus without hospitalization for mood disorders was compared using conditional logistic regression analyses with adjustment for income, marital status, place of residence, and method of suicide.

RESULTS

A statistically significant spring peak in suicide was observed in both groups. A history of mood disorders was associated with an increased risk of suicide in spring (for males: RR=1.18, 95% CI 1.07-1.31; for females: RR=1.20, 95% CI 1.10-1.32).

LIMITATIONS

History of axis II disorders was not analyzed. Danish socioeconomical realities have only limited generalizability.

CONCLUSIONS

The results support the need to further investigate if exacerbation of mood disorders in spring triggers seasonal peaks of suicide. Identifying triggers for seasonal spring peaks in suicide may lead to uncovering novel risk factors and therapeutic targets for suicide prevention.

Deliberate self-harm in older adults: a review of the literature from 1995 to 2004

BACKGROUND

The prevention of suicide is a national and international policy priority. Old age is an important predictor of completed suicide. Suicide rates in old age differ markedly from country to country but there is a general trend towards increasing rates with increasing age. In 1996 Draper reviewed critically the evidence on attempted suicide in old age in the 10 years between 1985 and 1994. The review highlighted a need for prospective controlled studies in older people with more representative samples as well as studies examining the interaction of risk factors, precipitants, motivations, psychopathology and response to treatment. The aim of this paper is to update this review and to summarise the advances in our understanding of DSH in later life.

METHOD

We have critically reviewed relevant studies published between 1995 and 2004 to summarise the advances in our understanding of factors associated with deliberate self-harm in later life.

RESULTS

The main advances in understanding have been to clarify the effect of personality and cultural factors, service utilisation pre and post attempt, and the (lesser) impact of socio-economic status and physical illness. Methodological weaknesses continue to include inadequate sample sizes performed on highly selected populations, inconsistent age criteria and lack of informant data on studies relating to role of personality.

CONCLUSIONS

Future studies should include prospective, cross-cultural research with adequate sample sizes and which are population-based. Such approaches might confirm or refute the results generated to date and improve knowledge on factors such as the biological correlates of deliberate self-harm, service utilisation, costs and barriers to health care, and the interaction of these factors. Intervention studies to elucidate the impact of modifying these factors and of specific treatment packages are also needed.

The dexamethasone suppression test as a predictor of suicidal behavior in unipolar depression

BACKGROUND

Non-suppression on the dexamethasone suppression test (DST) in unipolar depression has been found to be associated with completed suicide, with less consistent data for attempted suicide and hospitalizations for suicidality. The purpose of this study was to examine DST non-suppression as a predictor of these three aspects of suicidal behavior.

METHODS

Records were reviewed for 101 patients who met criteria for major depressive disorder and/or dysthymic disorder and had a DST performed. All patients were treated naturalistically and were followed for an average of 2 years. DST suppressors and non-suppressors were compared with respect to three outcomes: (1) completed suicide; (2) attempted suicide; and (3) hospitalizations for suicidality.

RESULTS

DST non-suppressors were significantly more likely to have completed suicide or be hospitalized for suicidality than DST suppressors, with a non-significant trend for attempts. Total suicidal events were also significantly more frequent in the non-suppressor group.

LIMITATIONS

Axis II diagnoses and severity of illness were not assessed. Knowledge of DST results may have influenced the decision to hospitalize patients.

CONCLUSIONS

DST non-suppression identifies unipolar depressed patients with a higher risk for future suicide completion or hospitalization for suicidality. Performance of DST upon initiation of treatment may be a useful adjunct in identifying suicidal risk.

Effect of comorbid alcohol and drug use disorders on premature death among unipolar and bipolar disorder decedents in the United States, 1999 to 2006

OBJECTIVE

The aim of this study was to quantify the effect of comorbid alcohol and drug use disorders on premature death, as reflected by the manner of death (suicide and other unnatural death versus natural death) and the age at death, among decedents with unipolar and bipolar disorders.

METHODS

This study is based on the US Multiple Cause of Death public-use data files for 1999 to 2006. Secondary data analysis was conducted comparing decedents with unipolar/bipolar disorders and decedents with all other causes of death, based on the death records of 19,052,468 decedents in the Multiple Cause of Death data files who died at 15 years and older. Poisson regression models were used to derive prevalence ratios to assess the effect of comorbid substance use disorders (SUD) on the risks for being an unnatural death among mood disorder deaths. Multiple-cause life table analysis and mean age at death were used to quantify the effect of comorbid SUDs on premature mortality among mood disorder deaths.

RESULTS

Prevalence of comorbid SUDs was higher among unipolar and bipolar disorder deaths than that among all other deaths. Among unipolar and bipolar disorder deaths, comorbid SUDs were associated with elevated risks for suicide and other unnatural death in both men and women (prevalence ratios ranging 1.49-9.46, P < .05). They also were associated with reductions in mean ages at death (ranging 11.7-33.8 years, P < .05). In general, these effects were much stronger for drug use disorders than for alcohol use disorders. Both SUDs had stronger effects on suicide among women, whereas their effects on other unnatural deaths were stronger among men.

CONCLUSIONS

This study is among the first to provide population mortality-based evidence to further establish comorbid SUD as one of the key risk factors for premature death among individuals with unipolar or bipolar disorders in the United States. Clinicians need to be aware of the potentially lethal risk associated with these comorbid conditions.

Augmentation of fluoxetine's antidepressant action by pindolol: analysis of clinical, pharmacokinetic, and methodologic factors

In a controlled trial, the beta-adrenoceptor/5-hydroxytryptamine-1A (5-HT1A) receptor antagonist pindolol accelerated and enhanced the antidepressant effect of fluoxetine. The median times to sustained response (> or = 50% reduction of baseline severity maintained until endpoint) were 19 days for fluoxetine plus pindolol (N = 55) and 29 days for fluoxetine plus placebo (N = 56) (p = 0.01). The response rate at endpoint was 16% greater in patients treated with the combination. The plasma concentration of pindolol remained stable between 3 days (first blood sampling) and 6 weeks. Mean values were approximately 26 nM, a concentration higher than the Ki of (-)pindolol for human 5-HT1A autoreceptors (11 nM). Plasma fluoxetine and norfluoxetine concentrations increased steadily until the fourth week of treatment. Fluoxetine concentrations were lower in patients receiving the combination (p = 0.043), but there was no significant relationship to the clinical response in either group. A reanalysis of the data using a survival analysis revealed that significant differences in the time to sustained response between both groups would have also been detected (1) in a 2-week trial, (2) without a placebo lead-in phase, and (3) with less frequent visits. However, the use of "response" instead of "sustained response" as measure of clinically relevant change would have greatly diminished the difference between treatment arms (p = 0.08 instead of p = 0.01). This emphasizes the need of using stringent outcome criteria in antidepressant drug trials. A comparison of the data of all sustained responders (N = 27) in the fluoxetine-plus-placebo group with the first 27 responders in the fluoxetine-plus-pindolol group (of a total of 38) revealed a highly significant difference in the time to sustained response (18 and 10 days, respectively; p = 0.0002). This indicates that the faster response in the fluoxetine-plus-pindolol group is not a result of the greater proportion of responders.

Hyperactivity of the hypothalamic-pituitary-adrenal axis and mortality in major depressive disorder

Convergent evidence indicates that HPA-axis hyperactivity is a risk factor for suicide in major depressive disorder, and seven independent reports have shown that patients with abnormal dexamethasone suppression test (DST) results have significantly higher rates of eventual suicide. The identification of interactions between DST results and other clinical predictors would enhance risk assessment, but modest sample sizes have limited such analyses in earlier cohorts. Subjects with major depressive disorder who participated in research protocols at the University of Michigan between 1980 and 1991, who had fully structured diagnostic interviews, and who underwent a 1-mg DST while actively depressed were screened with the National Death Index for a mean (S.D.) follow-up period of 18.0 (5.5) years. Of 334 subjects, 69 (20.7%) were identified as having died. Of these, 13 (18.8%) had died by suicide and 32 (46.4%) from cardiovascular causes. Baseline DST results did not significantly predict death from suicide or from cardiovascular disease for the sample as a whole. Significant relationships between DST results and later suicide did exist for inpatients, for patients with manifest suicidality and, in particular, for inpatients with manifest suicidality. Because nearly all previous reports of DST results and suicide described depressed inpatients, it is possible that the DST is a useful predictor only within this population.

The antisuicidal and mortality-reducing effect of lithium prophylaxis: consequences for guidelines in clinical psychiatry

The suicide-related mortality among patients with affective disorders is approximately 30 times higher, and overall mortality 2 to 3 times higher, than suicide-related mortality in the general population. Lithium has demonstrated possibly specific antisuicidal effects apart from its prophylactic efficacy: it significantly reduces the high excess mortality of patients with affective disorders. To date, suicide-prevention effects have not been shown for antidepressant or anticonvulsant long-term treatment. Clozapine appears to reduce the suicide rate in schizophrenia patients. Against this background, guidelines and algorithms for selecting an appropriate prophylactic strategy for affective disorders should consider the presence of suicidality in patient history. Appropriate lithium prophylaxis prevents approximately 250 suicides yearly in Germany, although lithium salts are infrequently prescribed within the National Health Scheme (specifically, to 0.06% of the population). Rational treatment strategies most likely would demand that prescription rates be about 10 times higher.

STin2 variant and family history of suicide as significant predictors of suicide completion in major depression

BACKGROUND

Suicide is the most serious outcome of major depression, yet not all depressed patients will commit suicide. Genes, along with other factors, might account for this difference. Serotonergic alterations have been observed in suicide and depression and impulsive-aggressive behaviors. Therefore, we aimed to identify predictors of suicide, considering genetic variation at the serotonin transporter (5-HTT) gene.

METHODS

We investigated the 5-HTT gene-linked polymorphic region (5-HTTLPR) and intron 2 (STin2) variants of this gene and their relationship to behavioral and clinical risk factors for suicide in a sample of depressed suicides (n =106) and depressed control subjects (n =152), diagnosed by means of proxy-based interviews.

RESULTS

We found a significant association of suicide completion with having at least one copy of the STin2 10 allele [chi(2)(1) = 10.833, p = .002]. No differences were found for the 5-HTTLPR variable number of tandem repeats. After controlling for behavioral and clinical risk factors for suicide, the STin2 variant remained a significant predictor of suicide in major depression when jointly considered with a family history of suicide (odds ratio 5.560, 95% confidence interval 1.057-29.247).

CONCLUSIONS

The STin2 locus might account, at least in part, for the observed familial aggregation of suicidal behavior. These results should be further explored in families where clustering of suicidal behavior is observed.

The prognosis of depression in old age: outcome six to eight years after clinical treatment

Previous studies suggest that the short-term outcome in severely depressed elderly in The Netherlands is worse compared to other studies in the Western world. The present study examines the long-term prognosis of hospitalized elderly patients with major depressive disorder and possible predictors of outcome. One hundred and five elderly inpatients with unipolar major depression, admitted by regional mental health services in a geographically delimited area, were evaluated six to eight years after index episode by trained residents using a structured diagnostic interview (C.I.D.I.) The GP was interviewed using a standard questionnaire. At follow-up 40% of the original sample had died. Of the survivors 33% had fared well, 24% had a relapsing course, 22% had residual symptoms, 11% were continuously ill, and 9% had probable dementia. With respect to prognostic factors, personality disorder predicted a worse outcome. All patients with a major depressive disorder at follow-up received specialised care and used antidepressants. None of the patients received ECT. The mortality rate in clinically treated elderly with major depressive disorder is high. Among survivors the long-term prognosis in The Netherlands is comparable with other studies to date. The presence of a personality disorder predicts worse outcome. Though the accessibility of services seems to be good, more vigorous treatment was not applied.

A study of suicides of older people in Sydney

BACKGROUND

Reports based on studies of coroner's files show that suicides in old age are commonly related to depression, but that in a majority of cases disability or ill-health is also a major factor. The aim of this study was to try to understand more clearly the precipitant causes of suicide in an older population.

METHOD

An Australian metropolitan coroner's office provided data concerning suicides in 1994-1998 of persons aged over 65 years.

RESULTS

Of 210 elderly people who killed themselves, 160 (76%) were clearly depressed, including a majority of the 24% deemed to have understandable reasons for suicide. Physical ill-health or disability was the major factor leading to suicide in 34% and appeared to contribute to suicidal ideation in another 24% of those who died; they had usually not been seen by psychiatrists.

CONCLUSION

Because depression is often treatable, even when associated with depressing circumstances, there is potential for further reduction of old age suicide rates by recognising and appropriately responding to symptoms of depression and distress.

Switching to the bingeing/purging subtype of anorexia nervosa is frequently associated with suicidal attempts

OBJECTIVE

Anorexia nervosa has the highest suicide mortality ratio of psychiatric disorders, suicide being associated with many factors. We assessed the first lifetime occurrence of these factors taking into account their possible overlap.

METHOD

Three hundred and four in- and out-patients with anorexia nervosa (DSM-IV) were systematically recruited in three hospitals of Paris suburbs, between December 1999 and January 2003. Patients were assessed by a face-to-face interview (DIGS). Current eating disorder dimensions were measured, and patients interviewed by a trained clinician to assess minimal BMI and, retrospectively, the age at which anorexia nervosa, major depressive disorder, anxiety disorders and switch to bingeing/purging type occurred for the first time, if applicable.

RESULTS

Major depressive disorder (p<0.001) and subtype switch from the restrictive to the bingeing/purging type (p<0.001) were the two factors significantly more frequently occurring before suicidal attempts, and remained involved when a multivariate analysis is performed, whether syndromic or dimensional measures are being used. Taking into account lifetime occurrence with a survival analysis, the switch to bingeing/purging type of anorexia appears as a major predictive factor, with a large increase of the frequency of suicidal attempts (OR=15) when compared to patients with neither major depressive disorder nor bingeing/purging type.

CONCLUSIONS

Bingeing/purging type of anorexia nervosa is largely associated with suicidal attempts, and may deserve specific attention. If confirmed on a prospectively designed study, these results would argue for early detection and/or more intensive and specific therapeutic intervention on this aspect of bingeing and purging behaviors.

[Poststroke depression: risk factors and effects on the course of the stroke]

The incidence of poststroke depression (PSD) varies between 20% and 25% as a major variant and an additional 10% and 20% as a minor variant. Its prevalence peaks 3-6 months after stroke onset. In nearly a quarter of all PSD patients, depressive symptoms persist over at least 2 years.Several longitudinal studies have identified different factors which may increase the risk of PSD. Most probably, the severity of the neurological deficit, female gender, history of previous psychiatric disorders, and bad social living conditions increase the risk of PSD. It is uncertain whether lesion location or size modulate PSD risk. Increasing age is not associated with a higher PSD incidence. In contrast, it is obvious that PSD is associated with less favorable outcome and higher mortality. The degree of disability and quality of life are significantly reduced in PSD patients. In conclusion, PSD is presently a not predictable complication of ischemic stroke which is significantly associated with less favorable outcome.Early diagnosis and adequate therapy are still necessary in stroke rehabilitation.

CSF 5-HIAA and DST non-suppression--orthogonal biologic risk factors for suicide in male mood disorder inpatients

Two biomarkers of suicide risk; non-suppression in the dexamethasone suppression test (DST) and low 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) have been reported to be predictors of suicide in mood disorders. The interrelation of the two systems seems to be different in suicide attempters compared with depressed inpatients who have not made a suicide attempt, indicating that the two biomarkers may be seen as independent. This investigation examined the interrelation of low CSF 5-HIAA and DST non-suppression in suicide victims with mood disorder. Fifty-eight mood disorder inpatients not receiving any treatment with antidepressants underwent lumbar puncture and the DST. Plasma cortisol levels at 8:00 a.m., 4:00 p.m. and 11:00 p.m. were analysed in relation to CSF 5-HIAA. All patients were followed up for causes of death and suicides were verified with death certificates. During follow-up (mean 21 years), 11 (19%) patients had committed suicide. In male suicide victims (n=6), the serum cortisol level at 4:00 p.m. showed a significant positive correlation with CSF 5-HIAA. Low CSF 5-HIAA predicted all early suicides (within 1 year), whereas all males who committed suicide after 1 year were DST non-suppressors. In female suicide victims (n=5), the post-DST serum cortisol did not correlate with CSF 5-HIAA. Low CSF 5-HIAA and DST non-suppression are orthogonal biologic risk factors for suicide in male mood disorder inpatients. CSF 5-HIAA is associated with short-term suicide risk; dysregulation of the hypothalamic-pituitary-adrenal axis seems to be a long-term suicide predictor.

Indicators of suicide over 10 years in a specialist mood disorders unit sample

BACKGROUND

There are few firm data to guide the clinician in identifying individual depressed patients who may be at high risk for completing suicide. In particular, there have been few prospective studies of well-characterized depressed patients to determine indicators of such future events.

METHOD

Eight hundred thirteen patients with a major depressive episode (DSM-III, DSM-III-R, or DSM-IV criteria) were assessed in detail in a specialist Mood Disorders Unit (MDU) over a 10-year period. Follow-up at the end of that period (mean = 5.1 years) confirmed that 31 patients (3.8%) had completed suicide. The suicide completers were compared on a broad range of clinical and demographic variables obtained at baseline with (1) the total remaining depressed sample, (2) 31 age- and sex-matched subjects who were confirmed to be alive and had never attempted suicide, and (3) 24 age- and sex-matched living subjects who had made at least 1 suicide attempt.

RESULTS

The most consistent finding, across all 3 comparisons, was that the suicide completers were more likely to have been inpatients at the time of the index MDU assessment. Other characteristics of completers were a greater number of prior admissions for depression, being older and in a relationship, and being male and married or female and single. Somewhat paradoxically, suicide completers also evidenced fewer previous suicide attempts and less suicidal ideation compared with living subjects who had attempted suicide at the time of index assessment.

CONCLUSION

Overall, we were able to find few predictors of later suicide in this sample. Those who completed suicide demonstrated evidence of more severe illness over a lifetime (for example, having more admissions). but revealed less suicidal ideation at the time of the index MDU assessment. While these features were statistically significant, they are of limited usefulness in predicting suicide in an individual patient.

Course and outcomes of depression in the elderly

Major depressive disorder is a potentially debilitating condition that often is unrecognized or undertreated in the elderly. Even when aggressively treated, the course of geriatric depression can be severe. There is growing evidence that suggests that late-life depression may carry a higher illness burden than depression with onset earlier in life, and that severity is linked to medical and psychiatric comorbidity. Data continue to accumulate in support of various treatment modalities, including medication, electroconvulsive therapy, and psychotherapy. Given the increased risk of adverse outcomes associated with geriatric depression, such as dementia and suicide, it is essential that future investigations continue to build on the evidence base supporting improved diagnosis and treatment of this complex disorder.